| Thousands
of individuals from around the world including patients,
professionals, and organizations have benefitted
from the work of Donald Meichenbaum, Ph.D. Dr. Meichenbaum
is Professor of Psychology at the University of
Waterloo in Ontario, Canada and a member of The
American Academy of Experts in Traumatic Stress.
He was the innovator of Cognitive Behavior Modification
(CBM) and at the forefront of the "Cognitive
Revolution" in the field of psychology in the
1970s and 1980s. He was voted one of the ten most
influential psychotherapists of the century by North
American clinicians in a survey reported in the
American Psychologist, the official publication
of the American Psychological Association. Dr. Meichenbaum
is Editor of the Plenum Press series on stress and
coping and serves on the editorial board of a dozen
journals. He has authored and coauthored numerous
publications including the classic Cognitive
Behavior Modification: An Integrative Approach
(1977), Stress Reduction and Prevention (1983),
Pain and Behavioral Medicine: A Cognitive-Behavioral
Approach (1983), Stress Inoculation Training
(1985), Facilitating Treatment Adherence: A Practitioner's
Guidebook (1987), and more recently, A Clinical
Handbook/Practical Therapist Manual For Assessing
and Treating Adults with Post-Traumatic Stress Disorder
(PTSD) (1994).
JSV: I know that you
keep quite busy as a clinician, lecturer, consultant,
researcher, and author. Can you tell me about the
various roles and/or positions that you currently
hold?
DM: I am a Professor at the University
of Waterloo who has recently retired. I am maintaining
a full lab, as well as being a clinical consultant.
I consult at a number of child, adolescent and adult
programs, inpatient and outpatient, where a sizable
percentage of the clientele have a history of victimization.
I am also the Editor of a series for Plenum Press
on stress and coping. And, perhaps, most exciting,
I recently became involved as the Director of an
Institute in Miami, Florida called "The Melissa
Institute." Melissa was a young lady who was
brutally murdered in St. Louis and her family has
recently established an Institute in her name designed
to explore issues on the prevention of violence
and the treatment of victims of violence. The intent
of the Institute is to bridge the gap between research
findings and practical applications. The Institute
is starting to take on more and more of a central
role in my functioning. It ties directly into my
work with victimized individuals.
JSV: When did you retire
from the University?
DM: Just this last July
JSV: Well, congratulations!
DM: That's not the way my mother
put it! My mother, who is 81-years old, works full-time
in New York City. When I told her that I was retired,
a perplexed look came upon her face. She said, "you're
retired and I am working full-time. What am I going
to tell my friends?" (laughs).
JSV: With so many exciting
changes taking place in the area of traumatic stress
(e.g., neurobiological findings, etc.), what things
do you believe are in need of greater investigation?
DM: That is really a big question
and I think the answer to it depends on which specific
population one is looking at. I don't think that
there are robust questions that cut across all populations.
In general, at the level of adult, we need to examine
the interrelationship between various spheres of
behavior. That is, neurobiological, psychosocial,
cognitive, and cultural. My own area of interest,
as we will get into in a moment, is trying to better
understand the cognitive arena. Once we have developed
a metric for each of these areas, then we can start
to look at the interdependence of these factors
across domains. A second major area that needs to
be explored that has not been looked at adequately,
involves the fact that three-quarters of the population
in North America is going to experience a Criterion
A event some time in their life (From the DSM-IV
this relates to an event that a person experiences
or witnesses that involves actual or threatened
death or serious injury or threat to the physical
integrity of self or others rendering the individual
feeling helpless or fearful). Yet, on average,
only about 25% of people develop posttraumatic stress
disorder (PTSD). An interesting and challenging
question is what distinguishes those individuals
who go on to develop PTSD from those who do not.
I think that explicating those differences can be
valuable in guiding both assessment and treatment.
The third and final area involves the role of cultural
factors in influencing the nature of traumatic responses
and the ways in which these are expressed. As an
Editor of the Plenum series, we have recently published
a series of books on the cross-cultural and intergenerational
features of traumatic stress. I think this latter
area has also been overlooked.
JSV: I know that you
have been a major proponent of the constructive
narrative approach for the treatment of trauma survivors.
Can you please describe the constructive narrative
perspective and how it is utilized with your patients?
DM: There are now a number of investigators
from different perspectives who have been very sensitive
and innovative in exploring the nature of the stories
that individuals tell about their trauma. Those
stories change over the course of time. The meaning
that a traumatic event has for individuals is critical.
This is not novel. A number of people have highlighted
the role of appraisal processes and the role of
the stories that people tell over the course of
time. I have become particularly interested in how
these stories change in my patients. I spend a good
deal of time supervising clinicians - psychiatrists,
psychologists, social workers- and we have audio
taped and videotaped therapy sessions. We have noted
that both symptom reduction and behavioral changes
covary with the changing nature of the accounts
that clients offer over the course of therapy. A
sense of personal agency often emerges. Clients,
over the course of therapy as they improve, often
shift the focus of their accounts. They now move
from viewing themselves as victims to becoming survivors
if not - thrivers. As they do so they offer interesting
accounts of how they can now often have many of
the same kind of thoughts, feelings, intrusive ideation,
etc. but this doesn't seem to bother them as much.
They do not feel "stuck." There is a certain
shift in the nature of their narrative. We have
become very interested in tracking these changes.
The challenge for us, at a research level, is whether
these narrative changes are epiphenomena that follow
behavioral changes and physiological changes or
whether these narrative changes play an instrumental
role in facilitating change. There are a number
of investigators who have studied victims of natural
disasters ( Harvey), rape victims (Foa et al.),
AIDS victims (Folkman and Stein), child sexual abuse
victims (Janoff-Bulman and Silver), each of whom
have highlighted the role of narrative changes.
The challenge for the field is that, at this time,
we don't know how best to analyze and code these
narrative accounts. The constructive narrative approach
is a set of clinical observations in search of a
methodology and a theory. Let me conclude by saying
that when bad things happen to people, the way they
tell others, as well as tell themselves "stories"
about the trauma, can influence their abilities
to cope. Also note, that how people cope can influence
the "stories" they tell. But often traumatized
individuals struggle to put into words, or into
some other form of expression, the impact of the
trauma. In their attempt to convey their distress
they often employ metaphors. "I am a
walking time bomb." "I am a victim of
the past." "This event opened up a can
of worms." "I am spoiled goods."
"I feel like I am on sentry duty all of the
time." Thus, in their own way, they become
poets. But these metaphors become more than figments
of speech. I believe they become ways in which individuals
come to construe and construct "reality."
One can view therapy as a way to elicit clients'
stories and to help them change their narratives.
In A Clinical Handbook/Practical Therapist Manual
for Assessing and Treating Adults with Post-Traumatic
Stress Disorder
(referred to as the PTSD Clinical Handbook),
I describe a variety of psychotherapeutic techniques
to accomplish these objectives.
JSV: On that note,
in 1994 you published A Clinical Handbook/Practical
Therapist Manual for Assessing and Treating Adults
with Post-Traumatic Stress Disorder. This compendium
of information is magnificent. In fact, the Administrative
Board of the Academy has recommended this publication
for professionals across disciplines. What motivated
you to develop that project and what were some of
your most memorable moments as you were compiling
it?
DM: I do appreciate your evaluation
and in fact, I have been quite pleased in how this
volume has been received and reviewed. I have been
a consultant for a number of years and in each setting
I am called upon to give presentations or supervise
cases. Given my obsessive-compulsive academic style
and my commitment to science, I would put together
various handouts on PTSD, depression, anger or addictive
behaviors, etc. People would ask me about assessment
instruments and interventions. In response, I would
put together a rather extensive handout. The Clinical
Handbook is the collection of these handouts
integrated into a format that hopefully people will
find helpful. You asked about the most anxiety-producing
feature of putting together the PTSD Handbook.
In each of the books that I had written previously,
I had given them to a publisher. In this case, I
decided to publish the Clinical Handbook
myself. This led to some anxiety and I had to convince
my wife that this high risk activity would not turn
out to be a Criterion A event! In fact, it took
an initial outlay of a large set of funds. In publishing
it myself, the proceeds from the Handbook are now
going toward the development of a research and clinical
training institute. So I now have been able to use
the royalties generated by the Handbook to support
graduate students, innovative research, and expand
training materials that clinicians may be able to
use. My dream is that we will eventually computerize
the Handbook so that clinicians will be able to
access this on a CD-ROM and call up specific clinical
problems, assessment issues, treatment concerns,
and even watch CD-ROM movies of master clinicians
demonstrating each of the core tasks of psychotherapy.
JSV: You have described
how the "art of questioning is the most critical
skill" for clinicians to develop. Why do you
believe this is the case and how do you apply this
skill in treating trauma survivors?
DM: If you go back to my comments
on the constructive narrative perspective, then
the therapist's "art of questioning" is
critical in eliciting and changing clients'narratives.
It is important to encourage clients to "tell
their stories" of what they have experienced
and the impact on them, their families and communities.
It is also important that the therapist elicit what
Paul Harvey, the radio commentator, calls the "rest"
of the story. Namely, what has the client been able
to accomplish in spite of the trauma? A way
to facilitate this disclosure is to have clients
use a timeline (or life chart) where they can indicate
when various traumatic events occurred in their
lives. On a second time line, the clients can indicate
what they have been able to accomplish in spite
of these traumatic events. The therapist can
not only elicit such accounts, but can then ask
clients to describe in more detail what they
had accomplished and how they were able to
do this. "How" questions are especially
helpful because they "pull" for the nature
of the strengths that individuals have and they
highlight the instrumental acts that individuals,
couples, groups and communities have been able to
implement to affect change. Thus, from my point
of view, the "art of questioning" not
only serves the function of assessment, but it sets
the direction for change in the clients' narratives.
Finally, it is hopeful that therapy will result
in clients becoming their own therapists - taking
the clinician's "voice" with them. I will
often ask clients if they ever find themselves out
there in the real world, asking themselves the kinds
of questions that we ask each other right here in
therapy? We want clients to "internalize"
the therapist's art of questioning.
JSV: Although many
people are exposed to traumatic experiences in their
lifetime, most do not develop posttraumatic stress
disorder (PTSD). What factors do you believe "buffer"
a person from developing full-blown PTSD?
DM: When I give workshops, I review
four classes of factors that I think distinguish
those who develop PTSD from those who do not. The
four general headings have to do with characteristics
of the trauma itself. There is a good deal of research
that highlights the nature of the objective features
of the traumatic event including its intensity,
its durability, and people's proximity to the event.
Another important aspect of these stimulus characteristics
is not only the objective features but also the
subjective features. There are a number of studies
that highlight that the meaning the event has may
play more of a role than the actual stimulus characteristics.
That is, does the individual feel that by their
actions or lack of actions, that they may have inadvertently
contributed to the traumatic experience? This can
play an important role in determining who develops
PTSD. For example, if the individual feels blameworthy
and guilty about the nature of their role in the
traumatic event, this would clearly increase the
likelihood of people developing PTSD. So, one whole
class of events involves stimulus characteristics.
The second class of events are response characteristics.
We know that the nature of the response that individuals
have in reaction to the traumatic event is critical
in determining who goes on to develop PTSD. There
are three features that turn out to be important.
One is how the person responded at the time of the
traumatic event. What has notably been characterized
as the acute stress reaction. Does the person show
anxiety, dissociation and the like? This may play
an important role in influencing the nature of the
reactions they encounter and the support that they
may receive.
Another element that becomes important
is the recognition that the reactions of traumatized
individuals change over the course of time. It is
not only important to recognize that clients have
symptoms, but when they have these symptoms is critical.
For example, a common referral problem is intrusive
ideation. Research by Baum and others indicates
that if intrusive ideation occurs down the road,
well after the event, it increases the likelihood
of PTSD. Also, is there comorbidity? That is when
the individual not only experiences what is considered
classical PTSD, but what is known as complex PTSD.
Are there comorbid responses such as anxiety, depression,
suicidal ideation, and what is often overlooked,
anger responses? Also, as I noted, are there guilt
reactions? This clearly complicates the nature of
the situation and increases the likelihood of developing
PTSD.
Two other factors play an important
role in determining who develops PTSD. There is
a good deal of research to implicate the role of
premorbid features; that is the nature of prior
exposure to victimization increases the risk of
developing PTSD. Whether one looks at the research
on combat, or on being a victim of crime, or many
other traumatic events, you find that prior exposure
both for the individual and their family or community,
can put individuals at high risk. There are a number
of other premorbid features in terms of socialization
patterns and the like that may also predispose individuals
to develop PTSD. For example, intergenerational
victimization becomes important. Some recent findings
highlight that when children are victimized, if
their parents have had a history of victimization,
it increases the likelihood of the children developing
PTSD. The last and perhaps the most overlooked factor
is the nature of the recovery environment. It is
not only what the person experienced and how they
reacted both at the time or down the road, or whether
this was the first time that they were traumatized
or not. We must also consider the nature of the
recovery environment - it can become critical. All
we have to do is compare the reactions and welcome
that Vietnam vets received versus those vets who
came home from Operation Desert Storm. There is
a clear need to explore the role that social support,
community work and the like play. Another aspect
that I think is overlooked, is the role that religion
plays in helping people cope with stress. I had
spent some time in Oklahoma City and saw the role
that the church played there. Moreover, in recognizing
that the major way that people try to cope with
trauma is by means of prayer or some kind of religious
ritual, I believe this highlights the need for us
to expand what constitutes the recovery environment.
JSV: As you are aware,
investigation of the effects of traumatic stress
in children is in its infancy. What issues do you
think are in need of greatest attention in this
area?
DM: This is a big issue for me
because I spend a good deal of time consulting at
residential programs with children who have been
victimized. The Melissa Institute is designed to
identify high risk children and their families and
communities and to develop prevention programs.
So there is a good deal that I could say about this.
I think that the major issue for me involves the
changing scenario of urban settings in the United
States where unemployment and violence, family dysfunction,
poverty, racism, and the like, are so rampant. The
epidemiological data highlights the widespread victimization
of children. I don't think that we have fully appreciated
the nature and impact of just how widespread traumatic
stress is for children. Also, there is an increasing
need to focus research on what constitutes resilience
factors for these children. I think that explicating
and building upon these resilience factors in terms
of preventative programs would be most important.
JSV: We are learning
more and more about the effects of secondary traumatic
stress such that caregivers themselves become traumatized
and/or overwhelmed through their efforts to assist
others. What advice do you have for those who treat
trauma survivors?
DM: Let me enumerate them in point
form. These are described in more detail in the
Handbook. If in fact clinicians have the
chance, they should not limit their practice just
to trauma survivors. Given the challenge of this
population and their often unresponsiveness to various
forms of treatment and the harrowing tales that
they have to tell, it would be helpful to include
the more traditionally "neurotic" types
of cases that are more treatment responsive in terms
of anxiety, marital distress and the like. This
is often not a possibility for trauma therapists
but if it is, I would encourage clinicians to pursue
it. Secondly, I think that therapists/clinicians
could benefit from debriefing. That is, having the
opportunity to share the impact of their trauma
work. One of the things that we know from the research
is that people who have had an opportunity to tell
their story to significant others do better in the
long run than those people who do not share their
stories. That clearly is an emerging finding in
the area of working with victims. Individual therapists
can develop coping techniques both within sessions
and between sessions and in spheres outside of therapy.
This can renew their faith which can become challenged
when dealing with trauma clients and horrific tales
of evil. In the same way that we know trauma can
affect the belief system and outlook of clients,
I suspect it can have a similar impact on therapists.
JSV: What do you perceive
as the most important factors for clinicians/professionals,
including non-mental health personnel, to consider
when intervening on behalf of a survivor of a traumatic
event?
DM: I think that the task of the
health care provider changes in terms of when they
intervene. If it is soon thereafter, then there
are a number of emergency requirements. Moreover,
the signature of the event becomes important as
to how one would intervene. At first, it is important
to make sure that people have information and that
they are safe. The clinician or health care provider
may act as a support agent and make sure that survivors
are protected from the media and well-wishers who
could make things worse. There is an immediate crisis
that needs to be addressed. Then there is a second
phase that has to do with education about the impact
of the trauma. Education about PTSD and discussion
about adaptive and maladaptive coping responses,
while normalizing and validating the nature of people's
reactions become important. As one proceeds, especially
if the impact of the trauma occurs over a prolonged
period of time, a major concern is that health care
providers often leave the scene too soon (i.e.,
see the research by Pennybaker). There are also
concerns about potential secondary victimization
and later on, anniversary effects. This is especially
the case if the victimization experience is of intentional
human design as compared to a natural cause. There
is often an increased likelihood of anger that has
to be addressed. How does one make sure there are
no comorbid reactions such as addictive behaviors,
depression, anxiety attacks and the like? It is
important that mental health personnel recognize
that people don't heal easily. You don't cure PTSD.
You don't stop the memories. In fact there is some
research that suggests that the more you intentionally
try to stop traumatic memories, the greater likelihood
that they are going to increase in terms of their
intrusiveness. Therefore, the question is how do
you help individuals transform memories? How do
you help people find meaning in such events? How
do you help them transform their pain into a "mission?"
This is all subsumed under the constructive narrative
perspective. If one sees the task of the health
care provider in this broader view, then what you
do right at that time of the event is only one small
parcel of the total intervention.
JSV: As you are aware,
The American Academy of Experts in Traumatic Stress
is a multidisciplinary organization with more than
one hundred professions represented. The Academy
recognizes that traumatic events are an unfortunate
part of the human experience that professionals
and workers from many fields work with on a regular
basis. What do you see as the major advantage of
an organization such as the Academy that is dedicated
to increasing awareness and ultimately, improving
the treatment for survivors of such events across
such an eclectic group?
DM: Well, I think that providing
an umbrella organization that will facilitate dialogue
as you do both in your journal and in other events
is a valuable service. What the physician, the emergency
worker, and the psychotherapist have in common and
how interventions can be coordinated across disciplines
is a valuable service. Such a dialogue should result
in better treatments for survivors and for those
who provide such services.
©1998 by The
American Academy of Experts in Traumatic Stress,
Inc. |
